Group Quote

LSS Insurance

Please fill in the information below so we can provide you with a price quote on your group health insurance. Or give us a call with the information. (435) 752-9493

Group Medical Insurance Quote Sheet

First Name:			Last Name:
Address:			City:
State:			Zip:

Phone Number:
Fax N umber:
E-mail:		Type of business:

# of full time employees:

(over 30 hours per week)

Census Information
ee-employee	es-employee/spouse	ec-employee/child	fam-family

#	Employee	m	/	f	age	ee	es	fam	ec	spouse age	# children
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15